This inspection was carried out on 29th November 2005.
CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.
The inspector found no outstanding requirements from the previous inspection report,
but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.
CARE HOME ADULTS 18-65
Creative Support 43 Station Road Crumpsall Manchester M8 5EB Lead Inspector
Sarah Oldham Unannounced Inspection 29th November 2005 10:00 Creative Support DS0000021608.V269280.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Creative Support DS0000021608.V269280.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Creative Support DS0000021608.V269280.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Creative Support Address 43 Station Road Crumpsall Manchester M8 5EB 0161 795 2477 0161 795 2477 sheila@cs-rehab.freeserve.co.uk Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Creative Support Ltd Sheila Reynolds Newby Care Home 5 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (5) of places Creative Support DS0000021608.V269280.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 14th July 2005 Brief Description of the Service: Station Road is a care home providing 24-hour support and accommodation for up to five (5) people whose support needs relate to their mental health. The service forms part of the North Manchester Rehabilitation Scheme. Creative Support and the Manchester Mental Health and Social Care Trust (MMHSCT) jointly fund the service. The building is owned and maintained by St Vincents Housing Association. The home is situated in the Crumpsall area of North Manchester and is close to transport links, local shops and leisure facilities. The house is sited on a residential street and is similar in style to other houses in the immediate area. The homes philosophy is based upon empowering people and ensuring that they are proactively involved in planning to meet their needs. Bedroom accommodation is provided on the first and second floors. All bedrooms are single and are fitted with wash hand basins. The home does not have a passenger lift and access to the first and second floors is via a central staircase. The home is therefore unable to offer a service to people with a high level of impaired mobility. Communal space is provided on the ground floor with two lounges and a large kitchen area. Laundry facilities and a games room are located in the basement. Creative Support DS0000021608.V269280.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over the course of 3 hours on Tuesday 29th November 2005. During the inspection discussions were held with the manager, senior and staff and two residents who were present at the home. Time was spent examining records, documents, the residents and staff files. A tour of the building was also conducted. There had been no complaints received about the home since the last inspection. Creative Support and Manchester Mental Health and Social Care Trust jointly fund the home. During this inspection only a selection of the key National Minimum Standards were assessed therefore in order to gain the full picture of how the home meets the needs of residents this report should be read with any previous inspection reports. What the service does well:
Creative Support and Manchester Mental Health and Social Care Trust jointly fund the service. The teams work in conjunction with one another to provide support to the residents at the home. All prospective residents are admitted to the home following a multi disciplinary assessment. Due to the different levels of paperwork required by the organisations involvedthere could be confusion over who was responsible for completing what. It was encouraging to note that the senior staff team had worked hard to ensure that recording systems worked in conjunction with one another and there were clear records maintained regarding the ongoing support to the residents. This ensured that there was a cohesive service provided. The atmosphere in the home was warm and welcoming. Residents living at the home said that they felt settled and supported by staff. Staff were observed to be pleasant and courteous to the residents and addressed the residents needs. Creative Support DS0000021608.V269280.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Creative Support DS0000021608.V269280.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Creative Support DS0000021608.V269280.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed at this inspection having been assessed at the previous inspection. There were no outstanding requirements from that inspection. EVIDENCE: Creative Support DS0000021608.V269280.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 9 &10 Residents were involved in planning their care and were encouraged in making decisions and choices within a risk assessment framework. EVIDENCE: A sample of care plans were viewed and contained information about the resident. This included an introduction to the person, their identified aims and goals as well as their health care needs and how all identified needs would be met. The home operated a key worker system. This involved a named member of staff working in partnership with the resident to initially develop the care plan and then to continue working with the resident to review and amend the care plan as the needs, aims and goals of the resident changed. Residents at the home were also subject to the Care Programme Approach (CPA). Reviews were undertaken and details of the outcomes of the reviews were documented. The staff at the home also maintained clear records regarding the review to ensure that the aims and the objectives were clearly documented and acted upon.
Creative Support DS0000021608.V269280.R01.S.doc Version 5.0 Page 10 Risk assessments were undertaken as part of the initial recording of documentation and reviewed every six weeks. These were amended as required. Creative Support and the Manchester Mental Health and Social Care Trust had developed a joint risk assessment/risk management and joint Missing Person Policies and procedures. Creative Support DS0000021608.V269280.R01.S.doc Version 5.0 Page 11 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed at this inspection having been assessed at the previous inspection. There were no outstanding requirements from that inspection. . EVIDENCE: Creative Support DS0000021608.V269280.R01.S.doc Version 5.0 Page 12 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 Residents at the home were supported with their health care needs. Medication systems had been implemented to ensure that the health, welfare and safety of residents using the service were protected. EVIDENCE: The manager and senior had reviewed the medication practice following the pharmacy inspection. Medication was delivered to the home on a weekly basis and kept in individual locked cabinets within resident’s own rooms. One member of staff was responsible for the ordering of the medication. The manager undertook an audit of the medication on a weekly basis. Medication Administration Records viewed were recorded appropriately and signed by staff. The manager said that if any errors occurred they would be recorded as incidents. No incidents had been recorded. Residents who wished to administer and control their own medication would be assessed and a risk assessment undertaken to ensure that the individual was appropriately supported in accordance with the home’s policies and procedures.
Creative Support DS0000021608.V269280.R01.S.doc Version 5.0 Page 13 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 The home had a complaints procedure that was known to people who use the service and they knew how to make a complaint. The home’s policies and procedures served to protect people from abuse. EVIDENCE: There was a joint Complaints Policy and procedure developed by the Manchester Mental Health and Social Care Trust and Creative Support, which been agreed and implemented. This included the role and contact details of the Commission for Social Care Inspection. There was evidence to support that residents at the home knew how to complain. One resident spoken to said that if he had any concerns he would speak to the manager and was also aware on how to contact other agencies including the Commission for Social are Inspection (CSCI). The resident said that he felt that his complaint would be listened to and acted upon. A record was kept of all concerns and complaints raised by people who use the service. The home had not received any complaints since the last inspection. Creative Support DS0000021608.V269280.R01.S.doc Version 5.0 Page 14 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 25, 26, 27 & 28 The premises are safe and the home’s environment including the standard of hygiene was well maintained both internally and externally and private accommodation is well equipped and personalised. EVIDENCE: The home was well maintained both externally and internally. The lounge, kitchen and communal areas had been redecorated and refurbished. The manager said that the residents had been involved and consulted about the choice of colours and furnishings. One resident spoken to said that the home was very comfortable and he especially liked how the lounge had been decorated. The manager said that there were further plans to refurbish the bathrooms and toilet areas in accordance with the budget. The residents spoken to say that the bedrooms had all the furnishings and equipment that they required. They were supported to personalise their rooms as they wished them to be. Creative Support DS0000021608.V269280.R01.S.doc Version 5.0 Page 15 At the time of the inspection the home had one vacancy. The manager said that when a prospective resident came to view the home and their room it would be discussed with them what type of décor that they would like. Creative Support DS0000021608.V269280.R01.S.doc Version 5.0 Page 16 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32 & 34 The numbers and skill mix of staff appeared sufficient to meet the needs of the people accommodated. EVIDENCE: Creative Support provides a team of staff that includes the registered manager, a senior support worker and an activities co-ordinator. Their role is to provide support to the people who use the service with social, leisure, occupational and current and future housing needs. The Manchester Mental Health and Social care Trust (MMHSCT) provides a team of registered mental health (RMN) nurses (6) one occupational therapist and support workers (5). Their role is to meet the mental health care and dayto-day support needs of the residents. The manager said that she would be involved in the recruitment and selection of nursing staff as a member of the panel and that the senior nurse would be involved in the recruitment and selection of staff by Creative Support. The manager also said that residents were encouraged to be involved in the recruitment and selection of staff and invited to attend as a panel member. There had been a lack of response to this by the residents although training and payment had been offered.
Creative Support DS0000021608.V269280.R01.S.doc Version 5.0 Page 17 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed at this inspection having been assessed at the previous inspection. There were no outstanding requirements from that inspection. EVIDENCE: Creative Support DS0000021608.V269280.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score 3 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X 3 3 Standard No 24 25 26 27 28 29 30
STAFFING Score X 3 3 2 3 X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 X 3 X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Creative Support Score X X 3 X Standard No 37 38 39 40 41 42 43 Score X X X X X X X DS0000021608.V269280.R01.S.doc Version 5.0 Page 19 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA27 Regulation 23 Requirement Bathrooms must be refurbished to provide appropriate facilities to the residents of the home. Timescale for action 30/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Creative Support DS0000021608.V269280.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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